膝关节骨性关节炎阶梯化治疗的新进展(2023)骨性关节炎(osteoarthritis,OA)是一种严重影响患者生活质量的关节退行性疾病,而膝关节骨性关节炎(kneeosteoarthritis,KOA)在临床最常见,主要表现为膝关节疼痛和活动受限。膝关节骨性关节炎是发病率最高、临床最常见、病程长、阶梯性明显、对个体和社会损害最大的骨关节炎之一。由于种种原因,目前我国各地区、各级医院骨科诊疗水平发展不均衡,关节疾病的诊疗水平参差不齐,对膝关节骨性关节炎的诊疗缺乏系统性的培训、全面深入的认识,难以对膝关节骨性关节炎患者严重程度进行恰当判断,易导致不适合治疗或诊疗延误。有鉴于此,查阅国内外最新文献,聚焦对膝关节骨性关节炎阶梯化治疗:基础治疗、药物治疗、修复性治疗和重建治疗四个层次,经过充分细致、广泛深入、独立客观、科学循证的文献分析,总结形成膝关节骨性关节炎阶梯化治疗的图文并茂、容易理解掌握的新进展。以期本新进展为医务人员对膝关节骨性关节炎阶梯化的治疗工作,提供科学、规范、有效的参考。新进展的全文请见PDF文档。
传统标准的4个X线片:AP,inlet,outlet,andJudetviews_肥胖患者骨盆和髋臼骨折的经皮治疗(2011)Percutaneoustreatmentofpelvicandacetabularfracturesinobesepatients BatesP,GaryJ,SinghG,ReinertC,StarrA.Percutaneoustreatmentofpelvicandacetabularfracturesinobesepatients[J].OrthopClinNorthAm,2011,42(1):55-67. 转载文章的原链接1:https://pubmed.ncbi.nlm.nih.gov/21095435/ 转载文章的原链接2:https://www.sciencedirect.com/science/article/abs/pii/S0030589810000726?via%3Dihub AbstractAbodymassindex(BMI)greaterthan30isbecomingincreasinglycommonintheUnitedStates.Surgeryforpelvicandacetabularfracturesinthispopulationisparticularlyproblematicbecauseconventionaltreatmentoftenrequireslargesurgicalexposures.Thesurgeryforboththesefracturesistechnicallydifficultbecauseofthevolumeofsofttissueandpronenesstocomplications.Woundproblemsandinfectionsareparticularlycommonafteropensurgeryinobesepatients,andtheseincreaselinearlywiththeBMI.Inthisarticle,wepresentasmallconsecutiveseriesover14monthsonobesepatientswhounderwentpercutaneoustreatmentoftheirpelvicoracetabularfractures. KEYWORDSPercutaneous,Acetabulum,Pelvicring,Fractures Definedasabodymassindex(BMI)greaterthan30,calculatedastheweightinkilogramstotheheightinmeterssquared,obesityintheUnitedStatesisbecomingincreasinglycommon.DatafromtheNationalHealthandNutritionExaminationSurveyobtainedin2007to2008showedthat33.8%oftheadultpopulationwasobese.1Thesteadyincreaseinthispopulationover20yearshasbeendescribedasanepidemic,2althoughrecentdatasuggestthattherateofincreaseappearstobeslowing,bothinadultsandchildren.1,3Theimplicationsofthisexpandingobesepopulationforthetraumaorthopediccommunityareenormousbecausethispopulationisadiscreetgroupthathasadifferentphysiologyfromthegeneraladultpopulation.Obesepatientshavehigherratesofpreexistingcomorbidities;theirmetabolicresponsetotraumaisdifferentandtheyhavehigherratesofperioperativecomplications,suchaswoundsepsisandvenousthromboembolism.4-7Inaddition,thereisevidencetosuggestthattheobesepopulationisatagreaterriskofpelvicinjuriesthanthegeneralpopulation.8Throughmultiplestudies,surgicaltreatmentoffracturesinvolvingthepelvisandacetabulumhasbeenshowntocarryamuchgreatermorbiditywhenperformedinobesepatients.9-13Forpelvicringinjuries,overallcomplicationratesofsurgeryhavebeenreportedtobeashighas54%,withwoundsepsisbeingbyfarthebiggestcomponent.10Intheacetabulum,ratesofwoundinfection,thromboembolism,andoperativebloodlossarealsoincreased2-fold,andtheseratesfollowalinearrelationshipwithbodymass,withoverallcomplicationratesreachingashighas63%inmorbidlyobesepatients(BMI>40).9,13Withsuchabloodcurdlingcomplicationprofilefromtraditionalsurgery,aless-invasivesurgicaloptionforthesechallengingfracturesinthishigh-riskpopulationispotentiallyveryattractive.Iftheinfectionratealonecouldbereduced,withoutalteringfunctionaloutcome,itwouldyieldahugebenefit.Formorethan10yearsatourinstitution,wehavebeenpercutaneouslytreatingallpelvicringinjuriesandmanyoftheacetabularfractures,particularlyinhigh-riskpatients,suchasthosewhoareobese.Inthisarticle,wepresentasmallconsecutiveseriesover14monthsonobesepatientswhounderwentpercutaneoustreatmentoftheirpelvicoracetabularfractures. PATIENTSANDMETHODSAretrospectivereviewwasperformedusingourhospitalsurgicaldatabase,afterinstitutionalreviewboardapproval.Overa14-monthperiod,betweenJanuary2008andMarch2009,theauthorsperformedpelvicoracetabularsurgeryon117consecutivepatients.AchartreviewofeachofthesesurgeriesrevealedacalculatedBMIof30ormorein38patients.Heightandweightdatawereunavailableinonepatient,butnootherhistoryofobesitywasnotedintheirchart.Ofthe38obesepatients,24hadapelvicringinjury,17hadanacetabularfracture,and3hadacombinationofboth.Overall,theauthorstreated16pelvicringinjuriesand7acetabularfracturesusingpercutaneoustechniques,makingatotalof23fracturesin20patients.ThefracturetypesaresummarizedinTable1.Fullmedicalrecordswereavailableforreviewinall20patients. Table1SummaryofinjuriesinobesepatientsandtheirtreatmentAbbreviations:APC,anteroposteriorcompression;LC,lateralcompression. Themeanageofthe20patientswas35andtheaverageBMIwasalso35,withonlyonepatientexceedingthethresholdof40forbeingmorbidlyobese(discussedlaterinCaseExample:Patient14).Therewere14menand6women.PelvicringinjurieswereclassifiedusingthesystemofYoungandcolleagues14andacetabularfracturesbythatofLetournelandJudet.15Primaryoutcomemeasureswerepostoperativecomplicationsrequiringrepeatsurgery,woundinfection,deepveinthrombosis(DVT),pulmonaryembolus(PE),andradiographicappearancebothimmediatelypostoperativelyandatfollow-up.Deepwoundinfectionsweredefinedasthoserequiringsurgicaldebridement. RadiographicReviewPatientswithpelvicringinjuriesunderwentanteroposterior(AP),inlet,andoutletviewsonadmissionandateachfollow-up,whereasthosewithacetabularfractureshadAPandJudetviews.FracturedisplacementwasmeasuredusingpixelcalibrationwithastandardrulerfromthePictureArchiveCommunicationSystem(PACS-MagicWeb,SiemensInc,NewYork,NewYork,USA).Measurementswereperformedby2independentobservers(P.B.andJ.G.)andameancalculated.Wheremultipleviewswereavailable,measuresshowingmaximaldisplacementwerechosen.Forthepelvicring,themethodtheauthorsusedformeasuringdisplacementwasthesameasthatbyLeFaivreandcolleagues.16Ahorizontallineisdrawnacrossthesuperiorendplateofthefifthlumbarvertebra.Byusingthislineasareferencefromwhichtomakeeitherhorizontalmeasurements(in-line)orverticalones(perpendicular),themaximumdisplacementoftheanteriorandposteriorringcouldbemeasured.Displacementswerecalculatedbycomparingnormalbonylandmarkstoeitherthereferencelineoraperpendiculartoit.Whentherewerebothpelvicringandacetabularfractures,bonylandmarksthatwerenotinvolvedwiththehipinjuryandwhosepositionwasfixedtotheconstantfragmentoftheiliumwerechosen.Thereductionpostoperativelyandatlatestfollow-upwasrecordedandgradedaccordingtothemethodofTornettaandMatta,17withexcellentgradebeingaresidualdisplacementof0to4mm;good,4to10mm;fair,10to20mm;andpoor,greaterthan20mm.Fortheacetabularfractures,choosingagradingsystemwasmoredifficult.TheauthorsusedthesystemofAndersonandcolleagues,18recentlydescribedfortheassessmentoffemoralheadmedializationafteramodifiedStoppaapproach.ThisapproachinvolvestakingalinefromthespinousprocessofL5downtothesymphysispubisandmeasuringthedifferenceinthedistancebetweenthislineandthecenterofthefemoralheadoneachside.Wehavegradedthisasgood(0-4mm),fair(4-10mm),andpoor(greaterthan10mm).Oursecondoutcomewasradiologicalsignsofarthriticchangeatfinalfollow-up,graded1to4(1,normalappearance;2,osteophytes;3,narrowedjointspace;4,boneonbone). SurgicalTechniqueGeneralconsiderationsForboththepelvicringandacetabulum,patientswerepositionedsupineonaradiolucentbedwiththeabdomenandipsilaterallowerextremitypreppedfree.Theweightlimitoftheoperatingroomtablewascheckedinsupermorbidlyobesepatients,andnitrousoxidewasavoidedwithanesthesiabecauseexcessivebowelgascanlimitfluoroscopicvisualization.Intra-abdominalcontrastwasflushedoutwherepossible.Patientswereparalyzedduringsurgery.Postoperatively,patientswererestrictedto3monthsoftoe-touch-weightbearingonthesideofthepelvicringinjuryoracetabularfracture. PelvicringThetechniqueweusedforpercutaneouspelvicringfixationhasbeenwelldocumentedinthepast16,19andinvolvestheuseofapelvicreductionframe.(Fig.1)Inshort,thissystemenablesonesideofthepelvistobestabilizedtotheoperatingtable,whiletheothercanbemanipulatedandfine-tunedwithahighdegreeofradiologicalaccuracyandcontrol.Oneofthestrengthsofthissystemisthatitallowsnear-anatomicreductionsofthepelvicring,withouttheneedforeitheropenapproachesormultipleassistants.OurstandardfixationwaswithtranssacraliliosacralscrewsinbothS1andS2,althoughthisvariedaccordingtopatientanatomy.Fortheanteriorpelvicring,thetechniqueoffixationdependedonthefractureconfigurationandthesofttissueenvelope.Althoughsomesymphysealdisruptionsweretreatedwithastandardplateandscrews,whensofttissueswerepoororthefracturewasopen,anexternalfixatorwasused.Inonecase,acerclagewirewasused.Pubicramusfracturesweregenerallytreatedwithcolumnscrewsinthisstudy. Fig.1.(A)Imageofthepelvicreductionframethatallowsforclosedmanipulationofpelvicringinjuries.(B)ClinicalimagedemonstratingtheuseoftheStarrFrame.Theframehasbeenanchoredtotherighthemipelvis.Distalfemoralskeletaltractionwasusedontheleftfemurtoassistwithclosedreductionofthedisplacedlefthemipelvis.NotehowtheframeallowsforappropriateC-armpositioning.(CourtesyofStarrFrameLLC,Richardson,TX.) AcetabulumScrewpathwaysforfixingacetabularfracturesarewelldescribedintheliterature20andarenotdiscussedhere.Reductionmaneuverscanbedividedintoclosedandopentechniques.Inanyperiarticularfracture,thereareusuallysomecapsularattachmentstothejointfragments,whichremainintactaftertheinjury.Ifpatientscanbeboughttotheoperatingroomwithinafewhoursoftheiraccident,simplefracturepatternssuchastransverseconfigurationscanbereducedbymanipulationofthehip.Themostcommonlyused,ofcourse,isin-linetraction,butforcedinternalorexternalrotation,flexion,andabductionareallmaneuversthathaveyieldedanatomicreductionsforus.Clearly,astimepasses,theseclosedreductionmaneuversbecomeincreasinglyunlikelytoworkandmostdisplacedacetabularfracturesrequiresomeformofopenreductionwithminiincision.Withthehipflexedup,weperformopenreductionswithminiincisionthroughasmalllateralwindow,approximately1to2cmbehindtheanteriorsuperioriliaccrest.A3-to5-cmincisionismade,andaftersharplydissectingofftheobliqueabdominalwallmuscleattachmenttothecrest,aCobbelevatorcanbepasseddowntheinnertabledirectlyontothefracturefragments.Inhighjuxta-andtranstectalinjuries,thefracturelinescanbedirectlypalpatedwithafingerthroughtheminilateralwindow,whichgivesanadditionalreadingforreductionoverfluoroscopyalone.SpecializedpelvicreductionclampshavebeendesignedanddevelopedbyCharlesReinert,whichhavesufficientexcursiontoallowclampingoffracturesaroundvoluminoussofttissueenvelopes(Fig.2).Theseclampsallowfortransversefracturestoberotatedandcompressed,foradisplaceddomefragmenttobesqueezedbackdown,andforquadrilateralplatemedializationtobekeyedin.Thecombinationoftraction,specificmanipulation,andpercutaneousclampsallowsustoachievefluoroscopicallyexcellentreductionsinmostofthesecases.Ifwethinkthatanexcellentreductioncannotbeachievedminimallyinvasively,wetreattheseinjurieswithopeninternalfixationviawell-describedapproaches.21,22Weshouldalsostressthatthisapproachisnotstraightforwardsurgery,particularlyinthosewhoareobese,andisatechniquethathasevolvedatourinstitutionoverthelast10to15years.Eachfracturepatternisuniqueandrequiresaslightlydifferentscrewconfigurationandreductionmaneuver.Weadvisesurgeonswhoarekeentotrythistechniquetobeginwithsimple,less-displacedfracturepatternsbeforemovingontomorecomplexones. Fig.2.(A,B)Picturesofclampsandothermanipulativedevicescreatedforpercutaneousmanagementofpelvicringinjuriesandacetabularfractures.(CourtesyofStarrFrameLLC,Richardson,TX.) Onceanacceptablereductionisobtained,thefractureisstabilizedwithlargefragment6.5-mmor7.3-mmcannulatedscrews.Thechoiceofscrewpathwaysisspecifictothefractureconfiguration. StatisticalAnalysisAllstatisticaltestsweretabulatedusingSASJMPv7software(SASInstituteInc,Cary,NC,USA).AStudentt-testwasusedtocomparemeansofcontinuousvariables.StatisticalsignificancewassetataPvalueoflessthan.05. RESULTSPelvicRingThe16pelvicfractureshadameanfollow-upof9.7months(3-24),andtherewerenodeaths.Onepatientrequestedtobetransferredoutofstatepostoperativelyandwassubsequentlylosttofollow-up.Themeaninitialdisplacementofthefractureswas22mm,andfinalreductionwasgoodorexcellentin15ofthe16patients,with7havingadisplacementof4mmorless.Noneofthefractureswentdownbyareductiongradebetweenpostoperativeandfollow-upradiographs.Therewasahighlysignificantdifferencebetweeninitialandpostoperativedisplacement(P=.0007)butnotbetweenthepostoperativeandfinaldisplacement(P=.54).PelvicringresultsaresummarizedinTable2. Table2Pelvicringinjuries:summaryofresultsAbbreviations:F,female;LC,lateralcompression;M,male. ComplicationsTherewerenoinfectionsinthisgroup,eithersuperficialordeep,andtherewerenopostoperativeDVTsorPEs.Threepatients,inwhomadequateprophylaxiswasimpossible,receivedtemporarycentralvenousfilters,butall3filtersweresubsequentlyremoved.Therewerenonewpostoperativeneurologicdeficits.Therewere2scheduledreturnstotheoperatingtheater,forsupplementaryanteriorfixation.Oneofthese(patient6)patientswasa34-year-oldmanwithAsevereAPcompression(APC)type3injury.Havingstabilizedhispelvicringposteriorly,theanteriorplatingwaspostponedby2weeksbecauseofanopenlaparotomywound,whichextendedverydistally.Oncehissofttissuesweremorecompliant,thesymphysiswasplated,withnofurthercomplications.ThesecondcaseisreportedlaterinthesectionPatient14:CaseExample.Theleastfavorableoutcomewasobservedina67-year-oldlady(theoldestinthisseries)withmoderatelydisplacedbilateralinsufficiencyfracturesandunilateralramusfracturesafterafalldownthesteps.HerBMIwas37,anditwasthoughtinitiallythatshecouldbetreatednonoperatively.However,asaresultofongoingpainandfurtherdisplacementobservedonserialradiographs,thepatientrequiredsurgeryat17days.Bilateralposteriorpercutaneousiliosacralscrewswerepassedafterclosedreductionwiththeframe,andpostoperativeradiographsshowedsomeimprovement(from15to11mmofdisplacement).However,herfollow-upradiographsshowedthatshehad“settled”backtothepreinjuryposition.Withadisplacementof16mmatfollow-up,thepatient’sresultwasgradedas“fair.”Therewerenocasesofheterotopicossification(Brookergrade2orworse)onthelastfollow-upradiographs,but3ofthe16patientswithpelvicringinjuriesdidundergoremovalofsymptomatichardwareafterbonyunion. AcetabulumThe7acetabularfracturestreatedpercutaneouslyhadameanfollow-upof9.1months(4-18months)withnonelosttofollow-upandnodeaths.Onepatienthadanundisplaced,transverse,posteriorwallfracture,butalltheotherswereinitiallydisplacedwithameanof17mm(9-22mm).PatientdatafortheacetabularfracturesaresummarizedinTable3. Table3Acetabularfractures:summaryofresultsAbbreviations:ACS,anteriorcolumnscrew;F,female;LC-2,LC-2screw;Magic,magicscrew;M,male;SAS,supra-acetabularscrew.aFailureoffixationbetween2and4weeks. ComplicationsTherewerenoinfectionsinthisgroup,eithersuperficialordeep,andnocasesofpostoperativeDVTsorPEs.Onepatient(describedlaterinCaseExample:Patient14)madeascheduledreturntosurgeryforsupplementaryanteriorfixationofherpelvicring,buttherewerenootherreturnstotheoperatingtheateracutely.Therewerenonewpostoperativeneurologicdeficits,andnoneofthepatientshaddevelopedheterotopicossification(Brookergrade2orworse)attheirlatestfollow-up.Immediatepostoperativereductionwasgraded“good”inallcases,buttherewasalossofreductionandsubsequentdevelopmentofarthritis(grade4)in2ofthe7casesrequiringtotalhipreplacement(patients17and19).Aged51and71years,thesepatientswereattheolderendofourgroup,andbothpatientshadcomplexfracturepatterns(T-typeandassociatedbothcolumn)inrelativelyosteopenicbonewithlargepreoperativemedializationofthehead(22and15mm).Inbothpatients,theinitialpostoperativepositionwasgood,withminimalmedicalization(2mminboth),noarticularstep,andnovisiblearticulargappinglargerthan1to2mmonanyofthe3views.Bothhadfailureoffixationbetween2and4weeksandwerereportedinthechartashavingbeenpartiallyweightbearing.Bythistimeitwasthoughtthatthesepatientswouldbebetterservedbydelayedhiparthroplastyratherthanrevisionfixation,andbothhavedonewellaftertheirhipreplacements.Discountingtheundisplacedfracture,forthe6displacedacetabularfractures,wehad2failuresoffixation,makinganoverallcomplicationrateof33%. CaseExample:Patient14Thepatientwasa21-year-oldpedestrianwhowasstruckbyacar.ShesustainedbilateralAPCinjuries,alongwithbilateraltransverseacetabularfractures,displacedontherightandundisplacedontheleft(Figs.3-5).Thepatientwasmorbidlyobese,withaBMIof45(thelargestofourseries).Afterapplyingtractionandabinderintheemergencyroom,shewastakentosurgeryonthedayofinjuryandthedisplacedacetabularfracturewasmanagedinitially.Througha5-cmlateralwindowandwiththehipflexed,aminimallyinvasivecollinearclampwaspasseddowntheinnertable,intothelessernotch.Withtractionanddeploymentoftheclamp,thefracturewasreduced.Thisreductionwasconfirmedbothbydirectpalpationwithafingerdowntheinnertableandbymultiplanarfluoroscopy.Thefracturewasreducedandstabilizedinthestandardfashion,withanteriorandposteriorcolumnscrews(6.5mmcannulated). Fig.3.(A)PreoperativeAPpelvisand(B)axialcomputedtomographicscanshowingadisplacedtransverserightacetabularfractureandbilateralAPCpelvicringinjuriesina21-year-oldwoman. Fig.4.(A)PostoperativeAP,(B)inlet,(C)outlet,and(D)Judetviewsshowsomeresidualwideningoftherightsacroiliacjoint,(E)butanotherwisewell-alignedpelvicringandacetabulum. Fig.5.(A-D)Radiographsat4-monthsfollow-upconfirmthatthesacroiliacalignmenthasnotchangedandtheacetabulumshowsnosignsofarthrosis. Thepelvicringwasthenreducedusingthereductionframe.Initially,theleft(leastunstable)sidewasreducedandthenfixedusinganS2iliosacralscrewgoingintothesacralbody.Theleftsidewasthenstabilizedtotheframeandtherightsidereducedontoit,usingtheframeelements.Onceagoodreductionwasachieved,finaldefinitivefixationwasplacedwithasingletranssacralS1screwandbilateralS2screws(allwere7.3mm).Atthispointitwasnotedthatthepatienthadaresidualsymphysealdiastasis,whichcouldbeonlypartiallycontrolledbyanexternalfixator.Itwasthoughtthatshewastoounstabletotoleratefurthersurgery,andtherefore,hersymphysealfixationwaspostponedby5days.ThroughaPfannenstielapproach,thesymphysiswasexposedbutcouldnotbeplatedbecauseofthenarrowramusbeingcompletelyfilledbya6.5-mmscrew.Thediastasiswasthereforecabledtogether,usingacablepasserthroughtheobturatorforamenunderdirectvision.Therewassomeresidualwideningof7mmoftherightsacroiliacjointafterthisprocedure,whichremainedlargelyunchangedatfinalfollow-up.Forbothacetabulumandpelvicring,thepatientwasgradedas“good”andshehadanotherwiseuncomplicatedfollow-up.Atlatestfollow-upthepatienthadsymmetricpain-freehipmovementsandwaswalkingwithoutaids.Therewasnoevidenceofearlyhiparthritis,butshewascomplainingofsomemildbacksymptoms. DISCUSSIONPelvicringinjuriesandacetabularfracturesaresevereinjuries,whicharecommonlytreatedwithreductionandinternalfixationvialargesurgicalapproaches.Complicationsoccurinthebesthands,butwiththeobesepopulation,theyhavebeenshowntoincreasesharply,inanalmostlinearfashionwiththesizeofthepatient.9Ofthere-portedcomplications,infectionandwoundbreakdownarebyfarthemostcommon.Forthepelvicring,Semsandcolleagues10recentlydescribedtheirexperienceoftreatingpelvicfracturesin48obesepatients,comparingtheiroutcomestoalargercohortof134patientswhowerenotobese.Theinvestigatorsfoundthatcomplicationratesinobesepatientswere54%comparedwith15%inthosewhowerenotobese.Theyfoundnotonlysignificantlyhigherwoundcomplicationsintheobesegroup(25%)comparedwiththenonobesegroup(5.9%)butalsoasignificantlygreaterrateoflossofreduction(31%vs6%).Theinvestigatorsstipulateclearlythatalltheinfectionsandwoundproblemsoccurredaroundopenexposures.Therewerenoinfectionsinthe18patientsreceivingonlypercutaneoussurgery.Thismirrorsourfindingsfromthe16pelvicringinjuriesdescribedinthisarticleinwhichnoneofthepatientsdevelopedinfections.Ofthose16patients,4underwentsymphysealplatingthroughaPfannenstielapproachaspartoftheirfixation.Wehaveincludedthesecasesinourpercutaneouscohortbecausethereductionwasalldoneclosedandtheposteriorpelvicringwasuniversallytreatedwithiliosacralscrewsalone.Semsandcolleaguesnoteda14%infectionratewithanteriorplatingofthesymphysis;inoursmallseriesof4,therewerenoinfections,although2weredelayedbecauseofeithernon-compliantsofttissuesoranestheticissues.Semsandcolleaguesalsofoundthatlossofreductionwasclearlyaproblemintheobesepatients(31%inobesepatientsvs6%innonobesepatients),particularlyintheOrthopaedicTraumaAssociationtypeCinjuries.However,theinvestigatorswereunabletocommentonwhethertherewasadifferencebetweenthepercutaneousgroupandtheopensurgicalgroupintermsofreductionloss,soitisunclearwhetheropenreductionoftheposteriorpelvisconferredanysignificantbenefitintermsofstability.Wenotedonelossofpositionbetweenthetimeofsurgeryandfollow-up(patient13)makingacomplicationrateof6%. Ourpreviouslyreportedexperienceofpercutaneouspelvicringfixationhasalsoshownlossofpositionratestobecomparablewiththereportedoutcomesofopenreductions.16SincethefindingsofGriffinandcolleagues,23whofounda13%failurerateofunilateraliliosacralscrewsinverticallyunstablesacralfractures,wehavechangedourposteriorfixationtotranssacralscrews,whichpassrightthroughthesacrumandanchorinthetricorticalboneofthesacralalaandopposingilium.Anecdotally,sincemakingthischange,ourfailureratesinverticallyunstablefractureshavedecreasedandwefeelthatthisseriesreflectsthat.Porterandcolleagues12recentlypublishedastudysimilarlydesignedtothatofSemsandcolleague.Theycompared186nonobesepatientswith102obeseones.Intermsofwoundcomplications,theobesegroupwasatmuchgreaterrisk,witha39%incidencecomparedwith19%inthenonobesegroup.Failuresoffixationwereapproximatelyequalbetweenthe2groups,runningataround7%.ThisfindingismoreinkeepingwithLefaivreandcolleagues’16recentarticleinwhichnocorrelationwasfoundbetweenobesityandfinalqualityofreduction.Fortheacetabulum,complicationratesafteropensurgeryrangefrom38%to63%acrossdifferentstudies.13,24BMIandcomplicationratesappeartohavealinearrelationship,withstatisticallysignificantincreasesinoperativetime,hospitalstay,andbloodlossreportedinmorbidlyobesepatients.13Naturally,thereareseveraltechnicaldifficultiesassociatedwithperformingcomplexacetabularreconstructionsinobesepatients.Thesurgicalapproachesareusuallymoredifficult,requiringlongerdeeperincisionstoachieveadequatevisualization.Standardpelvicinstrumentationmaybedifficulttoapplyaroundtheexcessiveenvelope,andthesheervolumeofsofttissuecanmakepreoperativeandintraoperativeimagingverydifficulttointerpret.Porterandcolleaguesrecentlystated,“.operativefixationofdisplacedacetabularfracturesinthemorbidlyobesepopulationmaypossessacomplicationratethatoutweighsthepotentialforasuccessfuloutcome.”Percutaneousmanagementofundisplacedacetabularfracturesiswelldescribedbyseveralauthorsandcommonlypracticedtoimprovepainandpreventdisplacementincertainfracturetypes.25,26Percutaneoustreatmentofdisplacedfracturesremainscontroversial,withonly1previousreportintheliterature.27Intheobesepopulation,aminimallyinvasiveoptionoffersseveraladvantages,includingshorteroperationtimes,minimalincisions,negligiblebloodloss,andverylowinfectionrates.However,notallacetabularfracturetypesareamenabletopercutaneousfixation,andinourinstitution,thosefracturesthatarenotamenablearetreatedwithstandardopentechniquesviawell-describedextensileapproaches.21,22Undisplacedandminimallydisplacedfracturesinthispopulationaretypicallytreatedpercutaneously.Displacedtransversefracturesandthoseinvolvingtheanteriorcolumnarealsosuitableforminimallyinvasivesurgeryifanexcellentreductioncanbeachieved.However,displacedfracturesoftheposteriorwallandposteriorcolumn,alongwithT-typevariantswithposteriordisplacementarenotconsideredcandidatesforthistypeofsurgery.Inthisstudywehavepresented7acetabularfractures,6ofwhichweredisplaced.Notably,therewerenoinfections,nodeaths,noneurologicinjuries,andnocasesofprovenDVTorPE.Atfollow-up,therewerenocasesofheterotopicossificationrequiringexcision,andnonerequiredhardwareremoval.Muchofthepubliclyexpressedconcernaroundthepercutaneoustreatmentofacetabularfractureshasbeentheabilitytobothachieveananatomicreductionandtomaintainit.Inourseries,allofthefractureshadgoodreductionsimmediatelypostoperatively,withminimalmedializationandgoodarticularcongruity.However,2ofthefractures(33%oftheinitiallydisplacedones)diddisplacebetween2and6weekswithnegativeconsequencesforthehipjoint.Bothofthesepatientswereolderthanthemean(aged51and71years),withosteoporoticfractureconfigurationsandmayhavehadsomecomplianceissues,allofwhichmayhavecontributedtothefailure.InPorterandcolleagues’13recentstudy,theyreporteda10%lossoffixationintheobesegroupthatwasstudied,whichisclearlysuperiortooursmallseries.However,thislossoffixationhastobecounterbalancedbytheir46%woundcomplicationrate,the5%ofnerveinjuries,and3deaths,nottomentionthe5%ofpatientsrequiringexcisionofheterotopicossificationand15%requiringremovalofhardware.Mayoreportedanobesesubsetof21patientsfromacohortof105.Hereportedacomplicationrateof38%,whichwasmainlypopulatedbyinfectionsandwoundproblems(24%),withfailureoffixationin5%.24Russellandcolleagues11describedseveralunusualcomplicationsintheirseriesof12over-weightand5obesepatients,aspartofamuchlargercohortof131acetabularfracturestreatedwithopensurgery.Ofthecomplications,24%wererelatedtopositioningofthepatients,andafurther24%developedwoundbreakdown.Lossoffixationintheentirecohortwasonlyseenin2earlyambulators.Ourseriescontrastsstronglywiththeseotherstudies.Excludingtheoneundisplacedfracture,ouroverallcomplicationratewas33%,composedofthe2fixationfailures.Wesawnowoundproblemsorinfections,noneurologicinjuries,noDVTsorPEs,andnoproblemswithheterotopicossification.Bothofourfailuresoffixationwereinolderpatientswithmoreosteoporoticfractureconfigurations,andbothwerereportedintheirchartstohavewalkedontheirfixationearly.Nonetheless,itwouldseemthatpercutaneouslyfixedacetabularfracturesarelessresistanttoearlyfailurethanthosetreatedopen.Theissueisthereforewhetherweareabletoreducetheseearlyfailuresbyeitherbetterpatientselectionorbettersupervisionofpostoperativeweight-bearingstatus.Thisarticlehasseverallimitations.Itisaretrospectivereview,withalltheinherentshortcomingsthatcomewiththat.Thenumbersaresmallcomparedwithotherstudies,withonly16pelvicringinjuriesand7acetabularfractures,3patientsbeinginbothgroups.Itisthereforedifficulttoraiseanymeaningfulstatisticalanalysis.Wealsohavenocontrolgroupagainstwhichtocompareourresults.Wedidtreat10acetabularfracturesinobesepatientswithopensurgery(seeTable1),butwedidnotthinkthatthiswasavalidcontrolgroupbecausethesepatientshadbeendeemedunsuitableforpercutaneoussurgeryatthetimeofadmission.Thesepatientshadadifferentsetofinjurytypes,notamenabletominimallyinvasivesurgery,andwefeltthatadirectcomparisonwouldbemisleading.BMIwascalculatedfromheightandweightdatarecordedbythenursingstaffinthepatients’charts.However,wecannotbecertainofwhethertheseindiceswereformallymeasuredorsimplyvolunteeredbythepatients,makingtheiraccuracyuncertain.Self-reportingofheightandweighthasbeenshowntobecommonlyinaccurate.28Ourfollow-upwasshort(around9months)and1ofthepatientswithpelvicringinjurieswaslosttofollow-up.However,alltheinjurieshadunitedbythetimeoftheirlastappointment.Radiologicalendpointsremainaproblemforbothpelvicandacetabularfractures.Radiographsarerarelyofidenticalrotationandviewingangle,whichmakesforpotentialerrorsinmeasurement.Fortheacetabulum,applyingtheclassicalgradingsystemofMatta29afterpercutaneoustreatmentisproblematicbecauseitemphasizesreductionofboththecolumnsandthearticularsurface.Percutaneousfixationwith6.5-mmscrewsusuallyobscuresthevisiblejointlineonatleast2views,makingthisanunreliableparameter.Also,whentreatedpercutaneously,thequadrilateralplateoftenremainsmediallydisplaced,despitethedomefragmentandtheheadbeingreduced.Wethereforeusedradiologicalparametersthatcanbereliablymeasuredandthatcorrelatewithfunctionaloutcome.Anotherlimitationisthatpercutaneoustechniqueshaveevolvedovertimeatourinstitution,withthewholesurgicalteamcompletelyfamiliarwiththesurgery.Translatingthisproceduretoanothercentermightnotdeliverthesameresults,particularlyintheshortterm.Onthepositiveside,allsurgerieswereperformedbythesame2surgeons,withacommonpre-andpostoperativemanagementprotocolandrehabilitationschedule.Overall,thisstudyislimitedinseveralways,particularlybysize,buttheoutcomesofoursmallcohortofpatientsaresocontrastingwiththehistoricalliterature,wefeelthatitisworthyofreporting.Itisalso,toourknowledge,thefirstdescriptionofpercutaneousacetabularfracturefixationbeingusedinanobesepopulation. SUMMARYWebelievethatwithcarefulpatientselection,percutaneoustreatmentofacetabularfracturesisagoodalternativetotraditionalopenmanagementinhigh-riskpatientgroups,suchasthosewhoareobese.Forpelvicringinjuries,thereductionframeisaneffectivewayofachievingbonyalignmentofeachhemipelvis,regardlessofpatientsize.Wehavefoundthatpercutaneousstabilizationhasnotresultedinatendencytoloosereduction.Withonly1fixationfailureinthisseriesandnoreportedcomplications,webelievethatpercutaneoustreatmentofpelvicringinjuriesintheobesepopulationisacompellingalternativetoopensurgery.
运动学对线(KA)全膝关节置换(TKA)的适用证、禁忌症、手术技术(2021)Kinematicalignmentintotalkneearthroplasty WeberP,GollwitzerH.Kinematicalignmentintotalkneearthroplasty[J].OperOrthopTraumatol,2021,33(6):525-537. 转载文章的原链接1:https://pubmed.ncbi.nlm.nih.gov/34414467/ 转载文章的原链接2:https://link.springer.com/article/10.1007/s00064-021-00729-4 AbstractinEnglish,GermanObjective:Theobjectiveofkinematicalignmentintotalkneearthroplastyistoimplanttheprosthesisaccordingtotheindividualjointline,legaxisandligamenttension. Indications:Kneeosteoarthritiswithfailureofnonsurgicaltreatmentaccordingtocurrentguidelines. Contraindications:Severedeformityorinstabilityrequiringaconstrainedkneeprosthesis.Necessityofintramedullarystems. Surgicaltechnique:Medialparapatellarapproachtotheknee.Resectionofthecruciateligaments,themeniscusandtheosteophytes.Femur-firsttechniquewithdistalresectionofthefemur,theintramedullaryguideisonlyusedfortheextension/flexionpositioningofthefemoralcomponent.Thepositioninginvarus-valgusisorientatedaccordingtothenativejointlineaftercorrectionofchondralwear.Thedistalresectionshouldbeequaltothethicknessoftheprosthesisconsideringthechondralwear(upto2mm)andthethicknessofthesawblade(1mm).Therotationofthefemoralcomponentissetaccordingtotheposteriorcondylaraxisunderconsiderationofchondralwear.Theamountofresecteddorsalboneshouldcorrespondtothethicknessofthedorsalcondylesoftheprosthesis.Thealignmentofthetibiaisparalleltotheindividualjointline.Thisenablesreconstructionoftheindividualphysiologicalslope,rotationandthevarus-valgusaxis.Extensionandflexiongaparecontrolled.Asymmetriesbetweenthelateralandmedialjointspacearecorrectedthroughavarusorvalgusrecutofthetibiaaslongasthesurgicalplanninghasnotbeenachieved.Thehip-kneeangleiscontrolled;however,theaiminkinematicalignmentistoreconstructtheindividualaxesandligamenttensionsandnotastraightlegaxis.Persistingasymmetriesinligamenttensionareadjustedbyclassicalsofttissuebalancingtechniques.Differencesbetweentheextensionandflexionspacesarecorrectedbyadaptingthetibialslope.Releaseoftheligamentsisusuallynotnecessary;sometimesastrippingofthedorsalcapsuleisperformed.Afterthetrialimplantation,theoriginalprosthesisisimplanted. Postoperativemanagement:Functionalrehabilitationwithweightbearingastolerated. Results:RandomizedstudiesshowedabetterfunctionintheKneeSocietyScoreandabetterrangeofmotionwithkinematicallyalignedprosthesescomparedtomechanicalalignment.Availablemeta-analysesalsoshowedbetterresultsforkinematicallyalignedknees.Thefirstmid-termresultsofthisnewtechniquewithafollow-upof10yearsshowasurvivalrateof97.5%oftheprosthesis. Keywords:Functionalresults;Kinematicalignment;Legaxis;Ligamentbalancing;Mechanicalalignment. IntroductoryremarksMAinTKAisthestandardtreatmentandaimsforaneutrallegaxiswithahip–kneeanglewithin3°ofvarusand3°ofvalgusanda90°orientationoftheimplanttothelegaxis[1,2].Manypatientshaveahip–kneeangleapproximating180°,butithasbeenshownthatuptoonethirdofmenhaveaconstitutionalvarusofmorethan3°.Inthesepatients,mechanicalalignmentofthekneeprosthesismightbeabnormalorundesirableandwillalmostcertainlyrequiresomedegreeofmedialsofttissuerelease[3].Thisispossiblyoneofthereasonswhyupto20%ofpatientswithmechanicallyalignedkneearthroplastiesaredissatisfied[4–6].Kinematicalignment(KA)isarelativelynewtechnique,whichStephenHowellandcoworkersfirstreportedin2008[7].Theaimofkinematicalignmentistoimplantatotalkneeprosthesisaccordingtotheindividualanatomyofeachpatientbyreconstructingthepre-arthritichip–kneeangle,thepre-arthriticjointlineobliquityandthusthenaturaltensionoftheligaments(.Fig.1). Fig.1 aInkinematicalignmentthepre-arthritichipkneeangle(mechanicalaxis)andtheobliquepositionofthejointlinearereconstructed.Toachievethis,thelateraldistalfemoralangle(LDFA,mean87°)andthemedialproximaltibialangle(MPTA[medialproximaltibialangle])(mean87°)arereconstructed.bDuringwalking,themechanicalaxisofthelegisnotatrightanglestothefloorastheanklesarecloserthanthehips.Themechanicalaxishasanangleofapproximately3°totheverticalaxisduringwalking.Duetothisfact,thenativejointlineisparalleltothegroundduringwalking Theexpectedbenefitsofkinematicalignmentareamoreindividualreconstructionoftheanatomyofthepatientleadingtoamorephysiologictensionoftheligamentsandapatient-specificindividuallegaxis.Thisshouldleadtoamorenaturalfeelingofthekneeleadinginahigherdegreetoaso-calledforgottenjointandwiththistoahighersatisfactionofthepatients.Sincethegoalofkinematicalignmentistoreconstructtheindividualkinematicsofeachpatient,thisarticlewillshowthetechniquewithamedialpivotingprosthesis.Thistypeofprosthesishasamedialdeepdishedinlayandalateralflatdesign.Amedialpivotkneedesignaimstoreconstructthephysiologicalmovementwithalateralroll-backinflexion[8,9]. SurgicalprincipleandobjectiveTheobjectiveofKAinTKAistoimplanttheendoprosthesisaccordingtotheindividualjointline,legaxisandligamenttensionineverypatient.Thisisachievedbyreconstructingthepre-arthriticsurfacegeometryaccordingtotheheightofthechondralsurface,asitwasonthefemoralandtibialsidebeforedevelopmentofosteoarthritis.Therotationofthecomponentsisreconstructedaccordingtotheindividualkneerotationasmeasuredbytheposteriorcondylaraxis. Advantages–Reproductionofthephysiologicallaxityoftheligamentsovertheentirerangeofmotion–Preservationoftheorientationofthejointline–Reconstructionofthephysiologicallegaxisasitwasbeforetheosteoarthritis,“pre-disease”state–Intraoperativecontrolofthealignmentbycalliper-basedmeasurementsoftheresectedboneandcartilage–Possiblyimprovedfunctioncomparedtomechanicalalignmentwithfasterrehabilitation Disadvantages–Modificationisnecessaryinkneeswithcongenitaloracquiredpathologicdeformities,e.g.patellamalalignment.–Traditionalinstrumentsandimplantsnotdesignedforkinematicalignment–Nodataonlong-termoutcomeandimplantsurvival Indications–Kneeosteoarthritiswithfailureofnonsurgicaltreatmentaccordingtocurrentguidelines[10] Contraindications–Generalcontraindicationsforkneereplacementsurgery–Localinfection–Severedeformityorinstabilityrequiringa(semi-)constrainedkneeprosthesis–Necessitytouse(long)intramedullarystems–Extra-articulardeformity(intheopinionoftheauthorstheplanedLDFAandMPTA(medialproximaltibialangle)shouldnotexceed83°);inthesecasesakinematicalignmentcanbepossiblyperformedwithaslightcorrectionoftheMPTAorLDFA,respectively,orincombinationwithanextra-articularcorrectiveosteotomy.–Relative:subluxationofthepatellawithdysplastictrochlea(eventuallythepositioningofthefemoralcomponentshouldbeinaslightexternalrotation)–Relative:unicompartmentalosteoarthritisoftheknee(possibleindicationforunicompartmentalkneeprosthesis) Patientsinformation–Generalrisksofsurgery,suchasneurovascularcomplicationsetc.–Infection–Persistenceofcomplaintsandpain–Implantloosening,fracture,instability,allergytoimplantmaterial,arthrofibrosis,limitedrangeofmotion,stiffness–Persistenceofaslightvarusorvalgusdeformity(asbeforethedevelopmentofosteoarthritis)–Hospitalization4–6days–Approximately3–6monthsrehabilitationperiod Preoperativeworkup–X-rayimagingofthekneeincludinglong-legstandingradiographs,anteroposteriorandlateralviewsandaxialpatellaview–Preoperativeplanningincludinganalysisofthehip–kneeangle,thelateraldistalfemoralangle(LDFA),MPTA,thetibialslope(.Fig.2)–Individualthree-dimensional(3D)cuttingblocksmaybeusedasanalternativetechnique(notshownhere).Inthiscase,acomputedtomography(CT)scanwith3Dplanningisperformedduringpreoperativeworkup. Fig.2 Preoperativeplanning.Thehip–kneeangleis7°,thelateraldistalfemoralangle(LDFA)88.5°(1.5°valgus),themedialproximaltibialangle(MPTA)87°(3°ofvarus).ThekneeisplannedinkinematicalignmentwithreconstructionoftheLDFAandtheMPTA.Thiswillresultinvarusof1.5°,whichisthenativeconstitutionalvarusofthispatient.Aperpendicularlinedrawntothetibialjointline(inred)willhelpwiththeorientationoftheextramedullarytibialguideduringsurgeryinrelationtotheanklejoint.Inthiscase,thislinewillendatthesyndesmosis.IftheplanningshowsMPTAorLDFAoflessthan85°ormorethan95°,itshouldbecorrectedtostaywithintheselimits[11] Instrumentsandimplants–Conventionalinstrumentsforkneereplacementsurgerywithextramedullaryreferencingofthetibia–Distalreferencingguidesforthedistalfemoralcut(.Fig.3)–Tibialrecuttingguides(varus–valgusandslope;.Fig.4)–Highpressureirrigation(jetlavage)–Patient-specificinstrumentsasanalternativetechnique Fig.3 aThereare4differentreferencingguidesfortheorientationofthedistalfemoralcut.Thefemoralchondrallayerhasarelativelyconstantphysiologicalheightof2mm[12].Byusingthefirstguideshownontheleft,theamountofresectedboneandcartilagecorrespondstotheheightoftheprosthesis(9mm)andreconstructsthephysiologicalheightofthefemur.Theotherblocksareusedtoreconstructthephysiologicalheightofthefemurasitwasbeforetheosteoarthritisbegan.Theseconddisplayedblockwillbeusedinavalgusosteoarthritisinarightkneewithworncartilageonthelateralside.Ithasathickeningof2mmtowardsthebonysurfaceonthelateralsidecomparedtothe“unworn”guidetocompensateforthecartilagelossof2mm.Thisleadstoaresectionof7mmofbonelaterallyand9mmboneandcartilageonthemedialside.Thethirdblockisusedinavarusosteoarthritistoresect7mmofboneonthemedialsideand9mmofboneandcartilageofthelateralside.Thefourthblockisusedinthecaseofnomoreremainingcartilageonthemedialandonthelateralside.Thisleadsto7mmofboneresectiononbothsidestakingintoaccountthelostcartilageof2mmonbothsides.bThereferencingguidesareusedwiththeintramedullaryguide.Thisguideisonlyusedtosettheflexion/extensionposition,thevarus–valguspositionisnotfixedbythisintramedullaryguideduetotheoval-shapedsparewhole(arrow).Thevarus–valguspositionissetindividuallywiththereferencingguides.(WithpermissionfromMedactaInternational,CastelSanPietro,Switzerland) Fig.4 Specialrecuttingblocksareavailableforthetibia.Afterresectionofthetibiatherecuttingblocksallowaresectionwith2°morevarusorvalgusangle,respectively,oranincreaseordecreaseofthetibialslopeby2°.(WithpermissionfromMedactaInternational,CastelSanPietro,Switzerland) Anesthesiaandpositioning–Generalanesthesiawithorwithoutregionalanesthesiaorspinalanesthesia–Supineposition–Ifdesired,thetourniquetisappliedatapproximately20cmabovetheupperrimofthepatella;thetourniquetshouldbeusedasshortaspossible–Positioningofthelegwithkneerollandlegholder SurgicaltechniqueThekinematicalignmentisshownforarightkneewithvarusosteoarthritiswithamedialpivotingknee.Thetechniquecanbeusedinthesamemannerforavalgusknee.However,accordingtotheauthors,theremainingvalgusaxisshouldbelimitedtoamaximumof3°(hipkneeangle)inthesecases.(Figs.5,6,7,8,9,10,11,12,13and14) Fig.5Standardmedialparapatellarapproachtotheknee,identificationofthechondraldamage.Ifthereisremainingcartilageonthemedialside,completelyremovethecartilagebyusingaringcurette.Ifthelesswornsideshowspartiallyworncartilage,removeitcompletely.Removaloftheosteophytesandanteriorcruciateligament.Alsoassessforbonydefectsthatmustbetakenintoaccountforbonyresections Fig.6 Theintramedullarycanalisopenedcentrallyapproximately7–10mminfrontoftheposteriorcruciateligament Fig.7 aPositioningofthedistalresectionguide.Theresectionguide(shownin.Fig.3)ischosenaccordingtothecartilagewear.Inthecaseofavarusosteoarthritiswithworncartilagemediallyasshownhere,the“worn”guideisusedonthemedialsideandthe“unworn”guideonthelateralside.Ifthemedialcartilageisonlywornpartially,ithastoberemovedcompletely.Ifthechondrallayeronthelateralcondyleisalsopartiallyworn,itmustbecompletelyremovedandconsequentlythe“worn/worn”guideisused.Theintramedullaryguideonlysetstheflexion/extensionangle.Thevarus–valguspositionofthecuttingguidecanbepositionedindependentlyoftheintramedullaryguideduetoanovalconnection.Therotationofthedistalresectionguideandtherespectivevarus–valgusguideisorientedwithregardtotheposteriorcondyles.Withthistechniquethevarus–valguspositionofthedistalresectionblockissetaccordingtotheindividualanatomyofthepatientundercorrectionofthecartilagewear.Afterthis,itisfixedwithpinsandtheintramedullaryguideaswellasthedistalresectionguideareremoved.bAftercheckingwiththeangelwingthedistalresectioncanbeperformedwiththedistalresectionblock.cTheamountofresectedboneiscontrolledwithacalliper.Theprosthesisusedinthiscasehasathicknessof9mmdistally,sotheamountofresectedboneontheunwornsideshouldbe8mm(+1mmthicknessofthebonetakenawaybythesawblade).Onthewornsidetherewillbe2mmlessasthecartilageisworn,sothethicknessshouldbe6mm(+1mmthicknessofthesawblade).Ifthemeasurementswiththecalliperdonotshowthedesiredresections,approximately0.5to1.0mmcanberesectedononeside(lateral/distal)byanadditionalrecuttingwiththesawbladethroughthesamecuttingblockposition Fig.8 Afterthedistalresection,thechondrallayeroftheposteriorcondylesisexamined.Ifthisisintact(inmostofthecasesinvarusosteoarthritis,in55%ofthevalguscases),theposteriorreferencingfemoralsizerispositioned.Therotationissetat0°accordingtotheposteriorcondyles.Noexternalrotationisappliedasthegoalofkinematicalignmentisreconstructionoftheindividualjointlinesandthefemoralflexionaxis.Ifthechondrallayerisnotintact,itisremovedcompletelyanda2mmplatecanbefixedintheposteriorreferencingguidetoreplacetheworncartilage.Theguideisfixedwith2pinswithintheposteriorreferencingholesandthefemoralsizecanbedeterminedbypositioningthestylusontheanteriorcortex.Afterwardsthesizerisremovedandthepinsremaininplace Fig.9aThe4-in-1cuttingblockofthedeterminedsizeispositionedonthepins.Thesurgeonshouldcheckthatthereisnoanteriornotching.Inthenextstep,thedorsalcondylesareresected,andtheheightiscontrolledwiththecalliper.bSincetheprosthesishasadorsalthicknessof8mm,theresectedblocksshouldhaveathicknessof7mm(+1mmsawblade)measuredwiththecalliper.Inthecaseofaworncartilagethethicknessshouldbe5mm(+1mmsawblade+2mmconsideringthelostcartilage).Ifthecorrectresultisobtained,the3remainingcutsareperformed.Otherwise,theblockisrepositionedandthecutsarecorrected.Ifthedifferencetothetargetissimilaronbothsidesby2mm,theblockcanberepositionedunderpreservationofthepinsinthedifferentholesoftheblock.Ifonesideiswrong,thepinofthesamesidehastoberemovedandtheblockisrepositionedandfixedwithonepininthedesiredposition Fig.10 aThetibialresectionblockisplacedparalleltothenativetibialjointlineaftercompensationforcartilageandbonewear.ThetibialslopeandtheMPTAarereconstructed.Theangelwingcanbeusedtohelpassessthejointline.Asacontrolofthealignment,thepositionoftheextramedullarytibialguideabovetheanklejointcanbecomparedtothepreoperativeplanningandcorrectedifnecessary(Fig.2).Therotationissetaccordingtotheindividualphysiologicalrotation.Thisissetparalleltotheanterior–posterioraxisofthealmostellipticallyshapedboundaryofthearticularsurfaceofthelateraltibialplateau.Akagi’sline(inblue)canalsohelpintheorientation(linefromthetibialinsertionofthePCLtothemedialborderofthetibialtuberosity).Theresectionheight(8mmtarget)issetwithastyluspositionedonthelesswornsidenearthetibialtubercleand8mmofboneandcartilagenearthetibialtubercleisresected.bTheresectedtibiashouldbelaterallyandmediallysymmetrical,consideringcartilageandbonewear.Thetibialslopeshouldbereconstructed.Theamountofresectedboneismeasuredandshouldbe8mmclosetothetibialtuberclelaterallyandmedially Fig.11 Beforeanycorrectionofthetibialresectionisperformed,theextensionandflexionspacesaremeasured.Inkinematicalignment,theflexionspaceshouldbeslightlylooserlaterallytoreconstructthephysiologicalsituation.Thegoalisnottherestorationofarectangularspaceinflexion,buttoreconstructastablemedialflexiongapandaphysiologicallylaxerlateralflexiongapforlateralroll-back.Inextension,thespaceshouldberectangularandstable.Incaseofsymmetry,nofurtherresectionisnecessary.Incaseofdifferences,furtherstepsarerequiredasshownin.Table1 Table1 Fig.12Denervationofthepatellaandremovalofosteophytesandthelateralfacetofthepatella.Thedecisionwhethertoreplacethepatellaislefttothesurgeon.Afterthedesiredtensionoftheligamentshasbeenachievedthroughrecutsonthetibialside,thetrialscanbeinsertedandtherangeofmotion,tensionoftheligaments,andarticulationofthepatellaaretested.Thelegaxiscanalsobechecked;however,thegoalofKAisnottorestorealegaxisof180°,buttorestoretheprediseasestate(asdeterminedintheplanning,see.Fig.2) Fig.13 aIfthecheckwiththetrialcomponentsgivesasatisfyingresultconcerningrangeofmotionand,balancingofthekneeand,bthemovementofthepatella,thepreparationofthefemurandthetibiaiscompleted.Thetibialrotationissetaccordingtothephysiologicalrotation.Theoriginalprosthesisisimplantedandafinalcheckisperformed.Inamedialpivotingknee,theroll-backonthelateralsidecanbeseeninflexion.Thepatellashouldbespontaneouslycenteredwithinthetrochleathepositionofthepatellaisalsochecked.Finally,thecapsuleandwoundareclosed Fig.14PostoperativelonglegaxisafterimplantationoftheTKAwithkinematicalignment(samepatientasin.Fig.2):thehip–kneeangleis1.5°varus,theLDFA88.5°,theMPTA87°.Thusthepre-arthriticstatehasbeenreconstructed Postoperativemanagement–Applicationofasterilewounddressingandanelastocompressivebandage–Aneventualintra-articulardrainisremovedafter24h–Removalofthesuturematerialbetweenthe12thand14thdayaftersurgery–Thrombosisprophylaxisaccordingtotheguidelines–X-raycontrolsinthesurgicaltheatre,after6weeksandafter1yeararerecommended.After6weeksweperformalonglegaxis,alateralandakneeskylineMerchantviewarerecommended.Afterthat,x-rays(anteroposteriorandlateralview)arerecommendedevery2years(Fig.14).–Postoperativephysiotherapy:functionalrehabilitationwithweight-bearingastolerated.Activeandpassivemotionwithinthepain-freerangeofmotion–Musclestrengtheningundersupervisionofaphysiotherapist Errors,hazards,complications–Generalsurgicalrisksasforanykneearthroplasty–Malpositioningofthefemoralcomponentinthecoronalplane.Preventionbymeticulousremovalofthechondrallayeronthewornside.Ifthechondrallayerispartlydamagedonthelesswornside,completeremovalofitandutilizationofthe“worn/worn”guide(Fig.7)–Malpositioningofthefemoralcomponentinthetransversalplane.Especiallyinpatientswithalateralizedpatella,orientationaccordingtothePCAcanleadtopatellarmalalignment.Inthesecases,apreoperativeCTwithmeasurementofthePCAinaccordancetotheTEAisrecommended,sinceaslightexternalrotation(between0and3°)ofthefemoralcomponentmightbenecessaryinthesepatients.–Malpositioningofthetibialcomponentinthecoronalplane.Withstandardextramedullaryreferencing,3°varuspositioningismoredifficulttoachievethan90°positioningtothetibialaxis.Thisriskcanbeminimizedbyconsequentplanningtopredicteventualaccentuateddeformities(Fig.2),bydrawingtheverticalaxistothejointlineintheplanningandtocontrolthisduringsurgerywiththepositionoftheextramedullaryalignmentguideinrelationtotheanklejoint(Fig.2),andbymeasurementoftheresectedbonewiththecalliper. ResultsInrecentyears,severalrandomizedcontrolledstudieshaveproposedthatpatientswithTKAthatwerekinematicallyalignedcomparedtomechanicallyalignedTKAshadabetterfunctionintheKneeSocietyScoreorintheOxfordKneeScore[14–17].Althoughsomeotherstudiesshowednosignificantbetween-groupdifference,noneshowedbetterfunctionalresultsinthemechanicallyalignedgroup[18,19],andthreemeta-analysesconfirmedsuperiorresultsinfunctionandrangeofmotioninkinematicallyalignedTKAgroupsofpatients[20–22].Recently,Ameta-analysiswaspublishedthatincludedonlyrandomizedcontrolledtrials.Intotal,theresultsof371kinematicallyalignedkneeswerecomparedto376mechanicallyalignedknees.Theauthorsshowedadifferenceof7pointsinthekneefunctionscore,abetterrangeofmotionof4°andabettercombinedKneeSocietyScore,whichallfavoredkinematicallyalignedkneesincomparisontothemechanicallyalignedTKAs.Thefollowuplastedbetween6and24months[23].The10-yearsurvivalrateofmorethan222kinematicallyalignedkneeswasreportedtobe97.5%[24].Concernhasbeenraisedthatadeviationofthe90°positioningofthetibialcomponenttothemechanicalaxiscouldleadtoearlyloosening[25].Midtermresultsdidnotshowahigherrevisionrateforvarusorvalguspositioningofthetibialcomponent[11,26,27].Currently,however,morethan5°deviationfromthe90°targetarediscussedcritically[28],andnodefinitivelimitsweredefinedregardinglegaxisandjointline.Ifduringplanningasevereextra-articulardeformityisrecognizedwiththeMPTAorLDFAexceeding83°,intheopinionoftheauthorsarestrictedkinematicalignmentshouldbeperformedwithapartialintra-articularcorrectionofthedeformityto83°MPTAorLFDA.InthecasesweretheMPTAorLDFAexceed80°,anextra-articularcorrectionosteotomyisadvocatedandafterthisakinematicimplantationcanbedonerespectingtheligamenttensionofthepatient.However,noclearlimitshavebeendefineduptonowandtheserecommendationsreflecttheopinionandexperienceoftheauthors.Inpatientswithalateralizedpatella,apositioningofthefemoralcomponentparalleltothePCAcouldleadtopersistinglateralizationofthepatella.Furtheroutcomeassessmentsinthesepatientsaremandatorybeforethetechniquecanbefullyrecommendedinthesepatients.Inconclusion,thekinematicalignmenttechniqueshowsexcellentfunctionalresultsthatseemtobeatleastasgoodasthoseoperatedwiththemechanicalalignmenttechnique.Themidtermdataareverypromising.However,long-termresultswithsurvivalratesof80%after25yearshavebeenpublishedformechanicalalignment,andfurtherstudiesarenecessarytoconfirmthepromisingclinicalresultsinkinematicalignmentinthelong-term[29].
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